John Baker, our Managing Partner, has researched two railway accidents that happened at the same Somerset village 50 years apart. This research has been in support of Norton Fitzwarren's bid to receive a 'red wheel' heritage plaque from the Transport Trust in recognition of the villagers' efforts to rescue the victims in both crashes. The leader of the project, Mary Hayward, had seen our news article on the 1940 accident and asked if we could help with her research. Of course, we were delighted to help especially since both accidents had a significant 'human factor' element.​We have previously written a short article on the 1940 accident, but the accident of the 11th November 1890 was also blamed on 'human error'. In this accident the signaller, George Rice, forgot that he had left a goods train standing on the main line and allowed an approaching fast passenger train into the same section. The passenger train collided with the stationary goods engine, killing 10 passengers and seriously injuring many more.

John's research revealed several new facts about both accidents and also documented more about the victims and those involved. This research has been published on posters that will be displayed in Norton Fitzwarren Village Hall. Copies of the posters for download are included at the end of this article.

As part of the Red Wheel project, John was asked to give a radio interview to the BBC - this is now available on the BBC website.

​On the 17th November, the Transport Trust awarded Norton Fitzwarren with a 'Transport Heritage Site' award. We were delighted to attend to see the culmination of Mary Hayward's work to get the actions of the villagers recognised following these two tragic accidents.

On the 9 November 2016, a tram on the Croydon tramway network overturned at Sandilands. The tram had been travelling at 73 km/h when it entererd a curve that had a maximum speed limit of 20 km/h. The speed caused the tram to overturn as it passed through the curve, and resulted in passengers being thrown around inside the tram, with some being ejected through broken windows. Of the 69 passengers involved in the accident, seven died and 61 were injured; 19 seriously.The Rail Accident Investigation Branch's report has been released today and makes some far-reaching recommendations for the way tram operations in the UK are regulated and managed. Sadly, many of the recommendations are made about things that are already known about (and managed) in the rail sector, but which were not applied to tramway operations - tramways are often regarded as being more akin to road operations than rail operations. The accident at Sandilands makes it clear that rail sector engineering standards and management systems (for example fatigue management) are highly relevant to tram operations.The investigation report concludes that it is probable that the tram driver temporarily lost awareness on a section of route on which his workload was low. A possible explanation for this loss of awareness was that the driver had a microsleep, and that this was linked to fatigue. Exacerbating this was that there were few landmarks so that the driver was unable to quickly reorient himself.The report makes 15 recommendations to improve tramway safety. Some apply to the operator of the Croydon tram network (First Group), but many apply across all UK tram operations:

The Chartered Management Institute has just released a report that gives insight into how managers cope with adversity. The findings of the report, and the recommendations that it makes, are in line with what we experience.Understanding and managing risk (through tools such as the bow tie) and building a culture where failures are seen as an opportunity to learn (through effective investigation) are at the core of what we do.

The Chartered Management Institute (CMI) is the only chartered professional body for management and leadership, dedicated to improving managers’ skills and growing the number of qualified managers.

Follow the CMI on Twitter at @cmi_managers: if you're based in the South West of England you can follow the regional branch at @CMISouthWest.

On the 27th November 1944 3,500 tons of high explosives and an estimated 500 million rounds of rifle ammunition exploded underground at the RAF's munitions dump at Fauld in Staffordshire. The likely cause of the explosion was a spark from the brass chisel being used by an airman on a live bomb - a tool that was not permitted, but probably made the job easier. This spark set off a chain reaction amongst the live munitions. A nearby farm and lime works were completely destroyed and virtually every house in Hanbury village was seriously damaged. A 6 million gallon reservoir was breached, the flood waters causing severe damage. Seismographs across Europe registered the blast. Had the blast occurred above ground, the effect would have been similar to that of the nuclear explosions at Hiroshima and Nagasaki.The official inquiry found that there were several systemic failings that had contributed to the accident: management of the site was poor, allowing dangerous work practices to exist. Suitable manpower had been in short supply, so Italian prisoners of war (200 of them) were being used to carry out menial tasks. Rescuers were met with confusion; no-one knew who was trapped underground because the required register wasn't maintained.Approximately seventy eight people were killed, mostly civilians in the nearby plaster works and local people.

The crater is 90 feet deep and covers 12 acres.Despite the scale of the disaster, few people have heard of it. You can read more about the explosion at this local history website, and more images are available here.

Today marks the anniversary of a serious accident on the Great Western Railway at Norton Fitzwarren in 1940. 27 people were killed, and a further 75 were injured when their express sleeper train from London (carrying over 900 people) passed two signals at danger, derailed and overturned. The accident occurred at about 3.45 a.m. on a very dark, wet and windy night. The train had been routed from the main line to a relief line at Taunton, to allow another train (carrying newspapers) to pass. However, the driver was under the impression that he was still on the main line and continued to accelerate until he realised his error. By that time it was too late to bring the train to a halt. The train went through a set of catch points at about 45 mph (there to protect the main line). The locomotive tipped onto its side and the first six coaches telescoped into each other, blocking all four tracks. Luckily, the newspaper train had just passed the express - had the two trains collided the casualties would have been far greater. The causes of the accident still feature in rail accidents today. The driver, with over 40 years' experience, was probably operating on 'auto-pilot' - his experience worked against him as his actions became subconscious; including cancelling two warnings from the automatic signalling system. He had also lost his 'situational awareness', being unaware of which line he was running on; he had never before been diverted onto this line and the signals that applied to him were on the opposite side of the track from normal practice. Fatigue and other psychological factors were also likely to be present; the train was working during wartime blackout conditions, during the night and his home in London had recently been damaged by bombing.You can read the accident report on the Railways Archive website, and the story is told in detail in this contemporary newspaper report.

Human errors often have humorous rather than safety critical consequences. The two examples here illustrate system failures which caused embarrassment for the organisations involved, but probably nothing more.In the top example, a sub-contractor working on street repairs after gas main works made the road marking error. Instead of marking the temporary space as 'DISABLED', a rather different marking was made. The operator was probably doing the best they could - the real failure is in the system that allowed the error to occur. See the KentOnline news report for the full story.

Photo: BT.com

In this second example, road painters repeated a spelling error that was first introduced on the section of road two years previously. Here, 'MINUTES' was replaced with 'MINUITES'. Again, the error lies in the system somewhere, not with the individual carrying out the marking. For the full story, see BT.com.

Research by the International Atomic Energy Authority (IAEA) published in December 2013 showed that 80% of significant events at nuclear power plants can be attributed to human error, while only 20% can be attributed to equipment failure. For many years the belief has been that human error is an individual-focused phenomenon or motivational issue. However, it has recently been identified that approximately 70% of these errors are down to weaknesses in organisational processes and cultural values. These organisational deficiencies are often hidden in management processes, structures and values and can create workplace conditions that lead to a human error or reduce the effectiveness of risk control barriers. The full report can be viewed here.